A surgical calm to the storm: managing refractory electrical storms with bilateral thoracoscopic sympathectomy

Refractory electrical storms (ES) present a significant challenge in patients with structural heart disease, often persisting despite optimal medical therapy, catheter ablation, and ICD therapy. This study evaluates the efficacy and safety of bilateral thoracoscopic sympathectomy (BCSD) in reducing arrhythmic burden and improving clinical outcomes in this high-risk population.

A retrospective review was conducted at CHU Grenoble-Alpes, including 11 patients with ES secondary to cardiomyopathies treated with BCSD between 2019 and 2024. Baseline characteristics, surgical outcomes, and arrhythmic recurrence were analysed. The procedure involved bilateral video-assisted thoracoscopic surgery (VATS) targeting the stellate ganglion and T1-T4 sympathetic chain. Patients were followed up for arrhythmic recurrence, complications, and survival.

The median age of the cohort was 71 years, and 73% had ischaemic cardiomyopathy with a median LVEF of 30%. Immediate postoperative outcomes were favourable, with sinus rhythm restored in all patients. Complications occurred in 18%, including one case each of respiratory distress and vasomotor disturbance. ES recurrence was observed in 18% within 30 days and VT recurrence in 55% at a median of 6.9 months Survival analysis indicated a median survival time of 10 months.

BCSD is a viable option for managing refractory ES, offering significant arrhythmic control and symptom relief in the short term. The findings support the integration of BCSD into multidisciplinary care pathways for high-risk patients. Future studies are required to validate long-term efficacy and optimise patient selection.